38.2-5904 - Office of the Managed Care Ombudsman established; responsibilities.
§ 38.2-5904. Office of the Managed Care Ombudsman established;responsibilities.
A. The Commission shall create within the Bureau of Insurance the Office ofthe Managed Care Ombudsman. The Office of the Managed Care Ombudsman shallpromote and protect the interests of covered persons under managed carehealth insurance plans in the Commonwealth. All state agencies shall assistand cooperate with the Office of the Managed Care Ombudsman in theperformance of its duties under this chapter. The definitions in § 32.1-137.7shall have the same meanings ascribed to them in § 32.1-137.7 when used inthis section.
B. The Office of the Managed Care Ombudsman shall:
1. Assist covered persons in understanding their rights and the processesavailable to them according to their managed care health insurance plan.
2. Answer inquiries from covered persons and other citizens by telephone,mail, electronic mail and in person.
3. Provide to covered persons and other citizens information concerningmanaged care health insurance plans and other utilization review entitiesupon request.
4. Develop information on the types of managed care health insurance plansavailable in the Commonwealth, including mandated benefits and utilizationreview procedures and appeals, and receive and analyze the annual complaintdata required to be filed by each health carrier providing a managed carehealth insurance plan, as provided in subsection C of § 38.2-5804.
5. Make available, either separately or through an existing Internet Web siteutilized by the Bureau of Insurance, information as set forth in subdivision4 and such additional information as may be deemed appropriate.
6. In conjunction with complaint and inquiry data maintained by the Bureau ofInsurance, maintain data on inquiries received, the types of assistancerequested, any actions taken and the disposition of each such matter.
7. Upon request, assist covered persons in using the procedures and processesavailable to them from their managed care health insurance plan, includingall utilization review appeals. Such assistance may require the review ofinsurance and health care records of a covered person, which shall be doneonly with that person's express written consent. The confidentiality of anysuch medical records shall be maintained in accordance with theconfidentiality and disclosure laws of the Commonwealth.
8. Ensure that covered persons have access to the services provided throughthe Office of the Managed Care Ombudsman and that the covered persons receivetimely responses from the representatives of the Office of the Managed CareOmbudsman to the inquiries.
9. Upon request to the Commission by any of the standing committees of theGeneral Assembly having jurisdiction over insurance or health or the JointCommission on Health Care, provide to the Commission for dissemination to therequesting parties assessments of proposed and existing managed care healthinsurance laws and other studies of managed care health insurance plan issues.
10. Monitor changes in federal and state laws relating to health insurance.
11. Provide information to the Commission that will permit the Commission toreport annually on the activities of the Office of the Managed Care Ombudsmanto the standing committees of the General Assembly having jurisdiction overinsurance and over health and to the Joint Commission on Health Care. TheCommission's report shall be filed by December 1 of each year, and shallinclude a summary of significant new developments in federal and state lawsrelating to health insurance each year.
12. Carry out activities as the Commission determines to be appropriate.
(1999, cc. 643, 649; 2000, c. 922.)